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Wisconsin f certification vehicle form 2026

The document is a certification form from the Wisconsin Department of Health Services for verifying the need for Specialized Medical Vehicle (SMV) transportation for Medicaid members. It requires completion by a qualified medical provider who must assess and confirm that the member has a physical or mental impairment that prevents safe travel by common carriers. The form includes sections for member information, eligibility criteria, diagnosis verification, and evaluator details.

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Click ‘Get Form’ to open the Wisconsin F Certification Vehicle Form in our editor.
Begin by filling out Section I, Member Information. Enter the member's name, identification number, and date of birth if applicable.
Proceed to Section II to determine eligibility for specialized medical vehicle transportation. Answer the question regarding physical or mental impairments that affect safe travel. If 'yes', continue to Sections III and IV.
In Section III, provide diagnosis information. Check the appropriate box indicating whether the member is indefinitely disabled, legally blind, or temporarily disabled. If temporarily disabled, specify the expected duration.
Indicate whether the member requires a wheelchair or scooter and provide an explanation of why specialized transportation is necessary in the provided space.
Finally, complete Section IV by having the evaluating medical provider sign and date the form, along with their name, position title, National Provider Identifier, and optional taxonomy number.

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